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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803919
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:13:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/02/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240102152639
FACILITY NAME:WATERMARK AT NAPA VALLEY, THEFACILITY NUMBER:
286803919
ADMINISTRATOR:GRANT WEGNERFACILITY TYPE:
740
ADDRESS:4055 SOLANO AVENUETELEPHONE:
(707) 345-1480
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:240CENSUS: 127DATE:
01/11/2024
UNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Grant Wegner, AdministratorTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Resident eloped from facility
INVESTIGATION FINDINGS:
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On 1/11/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of initiating complaint investigation and was greeted by Administrator, Grant Wegner. LPA toured the facility, reviewed resident records and made observations during the visit.

Complaint alleges resident (R1) eloped from the facility without facility staff knowledge. Based on a review of facility records, on 7/13/2022, resident R1 had eloped the facility memory care unit and found to be outside of the community for approximately 20 minutes before facility was notified.

Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20240102152639
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WATERMARK AT NAPA VALLEY, THE
FACILITY NUMBER: 286803919
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2024
Section Cited
CCR
87705(j)
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87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidence by:**
Based on a review of facility records it was
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The faciltiy has completed full maitenance of all delayed egress exits for the memory care unit as well as implementing camera system. LPA and Administrator tested and found exit alarms to be in working order. Lastly, Administrator ensures compliance moving forward. Deficiency cleared at the time of visit.
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found that a resident (R1) eloped the facility despite not being able to able to be in the community by themselves. This is an immediate health and safety risk of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3